1) Treatment arrhythmias associated with cocaine-associated catecholamine excess
- We discussed a complicated case of an agitated patient with recent cocaine ingestion and atrial fibrillation and signs of heart failure.
- All types of arrhythmias have been described in cocaine toxicity from wide complex-tachycardia to supraventricular tachycardia
- Arrhythmias associated with catecholamine excess include SVT, Sinus Tachy, Afib
- Supportive therapy is the mainstay: cooling, IV fluid rehydration and benzodiazepines
- Other therapies for SVT/Afib may include IV CCBs
- For treatment of HTN may use IV phentolamine/nitroglycerine for HTN (beware of reflex tachycardia)
- It is important to avoid beta blockers in pts with possible cocaine intoxication as this results in un-opposed alpha and worsening hypertension and coronary vasoconstriction
- See the following article for more information: Cocaine toxicity and arrhythmias
2) Causes of elevated Lactate
- Type A lactic acidosis: From marked tissue hypoperfusion: Cardiogenic, septic shock, local decreased perfusion (compartment syndrome, necrotizing fasciitis), ischemic bowel, seizures (from increased O2 use)
- Type B lactic acidosis: Features of hypoperfusion are not apparent. Causes include toxin-induced impairment of cellular metabolism. causes include: liver failure (from impaired lactic acid utilization in gluconeogenesis in the liver), metformin use in renal failure (theoretical), malignancy (from direct production by malignant cells), cyanide, alcoholism, diabetes.
3) Causes of low BP not responding to fluids
- In the absence of cardiogenic or septic shock think of more unusual causes of low BP:
- Anaphylaxis
- Adrenal insufficiency - mets to adrenals, infarction of adrenals secondary to severe infection (Waterhouse-Friederichsen), hemorrhage/adrenal vein thrombosis,
- Hidden bleeding: retroperitoneal
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